Dr Arie Levine
It’s possible to have a conversation with patients about the risk of cancer with IBD treatments without scaring them away from adhering to therapy, the ECCO 2019 meeting was told.
Dr Arie Levine, a paediatric gastroenterologist at Tel Aviv University, Israel, said even the mention of cancer could cast a dark cloud over the consultation, particularly for children, “and from that point on, the patient and their family are only hearing the C word, not about how to manage their Crohn’s,” he said.
But while clinicians should not dodge the facts on cancer risk, they can use a few key facts and management strategies to reassure patients that the risk of cancer from treatments is minimal and manageable, according to Dr Levine.
In his overview of the evidence, he showed that the lifetime absolute excess risk of cancer was small, at around 1-2/1000 patient years, with no excess mortality. And notably, most of the excess cancers were adenocarcinomas such as colorectal cancer, which may also be due to inflammatory disease rather than treatment. Therefore it was worth emphasising to patients that treating the inflammation is one way they can manage the cancer risk, and that drug treatment may be protective against cancer.
There was also a lot of confusing and conflicting information about which drugs used in IBD may cause cancer, said Dr Levine. Although some studies had suggested thiopurines were associated with an increased risk of lymphoma in older patients, more recent reviews had shown the risk was only seen with combination therapy.
Conversely, while a recent study had portrayed infliximab as not being associated with malignancy, Dr Levine said the authors had inappropriately played down the increased risk of cancer seen with infliximab combination therapy with thiopurine.
The message should be to avoid combination therapies where possible, he said.
Dr Levine also noted that risk of lymphoma with IBD treatment was closely linked to Epstein-Barr Virus (EBV), particular in patients under 40, and it was therefore worth monitoring EBV status and basing treatment decisions on this.
“I would say don’t underestimate the angst that [cancer concerns] can cause the patient and their family, and it’s important to give patients hope,” he advised.
“The take home message is that we can reduce [cancer] risk for patients. Most importantly – and this is controversial – is that I think we should avoid combination therapy. We have a new armamentarium of drugs we can use first line, that don’t cause cancer and which reduce inflammation.
“And even if we have to use combination therapy we can limit the duration of exposure. I tell patients that they are not married to the drugs,” he said.
“So at the end of the day, by giving patients this information and changing our practice we can reassure patients that our goal is to make them better by making wise choices in therapy.”